asthma prescribing guidelines – adults and children over ...€¦ · pharmacotherapy based on...

Cannock Chase Clinical Commissioning Group

East Staffordshire Clinical Commissioning Group

North Staffordshire Clinical Commissioning Group

South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group

Stoke-on-Trent Clinical Commissioning Group

NHS Staffordshire and Stoke-on-Trent

Asthma Prescribing Guidelines – Adults and Children over 12 years

Inhaler choices in this guideline are different from previous versions produced by the APG & APC.

It is not expected patients controlled on established therapy will be changed without clinical assessment.

All NEW patients should be initiated on inhaler therapy as per these guidelines.

http://www.northstaffordshirejointformulary.nhs.uk/docs/gcp/

http://www.southstaffordshirejointformulary.nhs.uk/

http://www.northstaffordshirejointformulary.nhs.uk/docs/gcp/


1

Approved by North Staffordshire Area Prescribing Committee and South Staffordshire Area Prescribing Group August/September 2019 Review date: August 2021

1. Diagnosis of asthma in primary care

‘Red Flags’ and indicators of other diagnoses

Prominent systemic features (myalgia, fever, weight loss)

Unexpected clinical findings (e.g. crackles, clubbing,

cyanosis, cardiac disease, monophonic wheeze or

cyanosis, cardiac disease, monophonic wheeze or

stridor)

Persistent non-variable breathlessness

Chronic sputum production

Unexplained restrictive spirometry

Chest X-ray shadowing

Marked blood eosinophilia

Diagnosis of asthma is an ongoing process of reviewing

symptoms. “Suspected asthma” should be used until

diagnosis is confirmed.

The diagnostic algorithm is taken from the BTS

Asthma/SIGN 2019 Guidelines; note:

Probability of asthma is usually determined in primary

care on the basis of structured clinical assessment

Diagnostic tests are more useful when initial diagnosis is

uncertain (intermediate probability).

In patients with intermediate probability of asthma

spirometry can help identify any airways obstruction. If

positive, then reversibility test or assessing treatment

over 6 weeks can help confirm diagnosis.

In absence of obstruction (i.e. negative spirometry

finding) patients should be referred to secondary care

for challenge tests and/or fractional exhaled nitric oxide

(FeNO)

2


2. Overall management of asthma based on British Thoracic Society/SIGN Guidelines

Regular low dose ICS (Preventer)

•Low dose inhaled corticosteroid formulary options are:

•Clenil Modulite 200mcg 1 puff bd (MDI)

•Easyhaler beclometasone 200mcg 1 puff bd (DPI)

•Qvar 100mcg 1 puff bd (MDI)

•Pulmicort Turbohaler 200mcg 1 puff bd (DPI)

Low dose ICS + LABA

•Use low dose ICS/LABA single inhaler. Formulary options:

•Licensed 12 yrs +:

•Flutiform 50/5 2 puffs bd (MDI)

•Symbicort Turbohaler 200/6 1 puffs bd (DPI)


•Fostair 100/6 1puff bd (MDI)

•Fostair Nexthaler 100/6 1 puff bd (DPI)

•Duoresp Spiromax 160/4.5 1 puff bd (DPI)

Medium dose ICS

•LABA is beneficial but control is suboptimal use medium dose ICS/LABA single inhaler:


•Flutiform 125/5 2 puffs bd

•Symbicort Turbo 200/6 2 puffs bd

•Relvar Ellipta 92/22 1 puff once daily (DPI)


•Fostair 100/6 2 puffs bd

•Fostair Nexthaler 100/6 2 puffs bd

•Duoresp Spiromax 160/4.5 2 puffs bd

High dose ICS

•Step up to high dose ICS/LABA single inhaler:


•Symbicort Turbo 400/6 2 puffs bd

•Relvar Ellipta 184/22 1 puff once daily


•Fostair 200/6 2 puffs bd

•Fostair Nexthaler 200/6 2 puffs bd

•Duoresp Spiromax 320/9 2 puffs bd

•Flutiform 250/5 2 puffs bd

•Consider referral to secondary care if control suboptimal

On diagnosis patients should generally commence on low dose ICS. Early clinical re-assessment is essential as poor response is an indicator for further investigations. Sub-optimal response as explained in green box below necessitates stepping up treatment. Treatment may be started higher up the algorithm based on symptom severity. All patients should be prescribed short acting β2 agonists (SABA) for relief of asthma symptoms unless they are using MART regimen. See section 3 for further information on treatment review and stepping down. Consult local formulary for choice of SABA and ICS/LABA inhalers. Algorithm below suggests some common formulary options but does not cover all inhalers. MDI: Metered Dose Inhaler/DPI: Dry Powder Inhaler/ICS: Inhaled Corticosteroid/LABA: Long-acting β2 Agonists/LTRA: Leukotriene Receptor Antagonists

Maintenance and Reliever Therapy in a single combination inhaler (MART) is another treatment option that can be tried in patients who are not well controlled with standard medium dose ICS/LABA:

Symbicort 100/6 or Fostair 100/6: 1 puff bd maintenance plus 1 puff as required for relief of symptoms up to a usual maximum dose of 8 puffs per day.

Symbicort 200/6 or Duoresp Spriomax 160/4.5: 1 or 2 puffs bd as maintenance plus 1 puff as required for relief of symptoms up to a usual maximum dose of 8 puffs per day.

If LABA is ineffective or suboptimal then LTRA can be added: Montelukast 10mg daily (15 yrs +) or 5mg daily (6 to 14 yrs)

SR Theophylline is another add on treatment (after trial of LABA and LTRA) that can be used in conjunction with ICS±LABA±LTRA. See BNF for preparations and doses.

Long-acting muscarinic receptor antagonist (LAMA) Spiriva Respimat (2 puffs daily) can be used as add-on treatment taking into account the following factors:

Uncontrolled asthma on high dose ICS plus LABA or MART regime

LTRA tried or ongoing

Acute asthma attack In last year requiring oral steroids

Possibility of co-existing COPD

Start with low dose ICS and step up treatment if:

Using SABA ≥ 3 times a week

Symptomatic ≥ 3 times a week

Waking up 1 night a week

Asthma attack requiring oral corticosteroids in last 2 years

3


3. Asthma Management and Review

Smoking Check smoking status every time (do not assume). Also enquire about passive smoking.

Encourage to stop smoking and advise on avoiding passive smoking

Inhaler technique Check and demonstrate inhaler technique – not only for routine review but when considering stepping up treatment

When using combination of inhalers minimise variation in device

When stepping up treatment minimise change in device

Use spacer with pressurised metered dose inhaler if difficulty in using inhaler and when prescribing high dose inhaled corticosteroid

Inhaler video techniques can be found on https://www.rightbreathe.com/

Monitoring Use RCP questions:

Have you had difficulty sleeping because of your asthma symptoms (including cough)?

Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?

Has your asthma interfered with your usual activities (e.g. housework, work/school etc.)? Additionally check:

Use of rescue medication

History of asthma attacks (exacerbations)

FEV1 and/or PEF

Side-effects Complete control of asthma is defined as

No daytime symptoms No night time awakening due to asthma No limitations on activity including exercise No need for rescue medication FEV1/PEF >80% of predicted or best Minimal side effects from medication

Pharmacotherapy Based on learnings from National Review of Asthma Deaths (NRAD), 2014 ensure the following

Patient is not over-relying on short acting bronchodilators. Look for those who have requested 12 or more short-acting beta-agonists (SABA) in the previous year

and prioritise these patients for review. Consider ways in which to limit access to SABA until the patient has had an adequate review including working with local

pharmacists and removal from repeat prescription systems. Patients should not require more than 2-3 SABA in a year if their asthma is treated appropriately.

Patient is not using long acting bronchodilator (LABA) without inhaled corticosteroid (IC). To minimise the risk of using LABA without IC they should be prescribed

with an inhaled corticosteroid in a single combination inhaler.

Patient is adhering to preventer inhaled corticosteroid treatment. Reinforce this message at every opportunity. Check ordering frequency.

Stepping up treatment

https://www.rightbreathe.com/

4


Step-up treatment according to management algorithm on page 3 if control is sub-optimal. After stepping up patients will require review within 8 weeks. Stepping down treatment Stepping down treatment is only suitable if patient has been stable for 12 weeks otherwise there is risk of exacerbation. The decision to choose which drug to withdraw will depend on factors such as effectiveness, adverse effects and patient preference. Note that ICS should not be withdrawn but dosage can be reduced as advised below. After stepping down step back up again if patient is symptomatic during this period. Reduce dose of inhaled corticosteroid in stable patients every three months, decreasing dose by approximately 25-50% each time. Stable patient would be defined by criteria as explained above for complete control of asthma. Before deciding to reduce dose of steroid also check:

Any asthma triggers (e.g. risk of worsening asthma according to season)

Concordance with treatment: as well discussion with patient it is important to look at ordering pattern

Inhaler/spacer technique

Patient’s understanding and view about treatment

Lifestyle Advise on trigger avoidance Assess and treat associated disease (e.g. GORD, rhinitis) Offer dietary advice for overweight patients Offer annual flu vaccine Offer one off pneumococcal vaccine

Education Patients should know

Trigger factors

How to measure peak flow

What is good control

What is the regular dose of their inhalers and how much it can be increased

How to recognise when the condition begins to deteriorate and what action to take All of the above can be incorporated into a Personalised Asthma Action Plan. A good example of a template for this is available from Asthma UK: https://www.asthma.org.uk/globalassets/health-advice/resources/adults/adult-asthma-action-plan.pdf

Support Do not forget parents and carers

https://www.asthma.org.uk/globalassets/health-advice/resources/adults/adult-asthma-action-plan.pdf

5


4. Acute Asthma

Personalised Asthma Action Plan (PAAP) PAAP as a self-management strategy is a key component of patient education and is an effective means of reducing the risk of admission, emergency department visits and increased GP consultation due to acute asthma. Asthma UK provides a good template for PAAP: https://www.asthma.org.uk/globalassets/health-advice/resources/adults/adult-asthma-action-plan.pdf

Patients should be taught to recognise signs and symptoms of worsening asthma:

Frequent symptoms i.e. wheeze, breathlessness, cough etc.

Waking up at night due to asthma

Interference with usual day-to-day activities

Using short acting bronchodilator 3 times or more per week

Drop in peak expiratory flow (PEF) below 80% of best

Treatment changes that patients can institute themselves when asthma seems to be deteriorating:

Resuming ICS if they have stopped

Quadrupling ICS dose if they are currently using maintenance dose – a separate ICS inhaler may be required if patient is using ICS/LABA inhaler

Patients who are on MART can use maximum doses: Fostair 100/6 maximum of 8 puffs per day; Duoresp 160/4.5 or Symbicort 100/6 or Symbicort 200/6 – maximum of 8 puffs per day.

Alternative to using increased inhaled corticosteroid is taking oral steroid (e.g. prednisolone 40mg daily for 5 days). Oral steroid may also be required if symptoms are worsening and/or PEF drops below 60% of best

Use SABA as frequently as required

Management of acute asthma attack when presented in general practice Moderate asthma features

PEF > 50% to 75% of best or predicted

SpO2 ≥ 92%

Speech normal

Respiration < 25 breaths/min

Pulse < 100 beats/min Management

SABA via spacer one puff every 60 seconds up to a maximum of 10 puffs. As an alternative or if no improvement use nebulised SABA e.g. salbutamol 5mg (preferably oxygen driven)

Start prednisolone 40mg daily

Routine prescription for antibiotic is not necessary but should be issued if clinically indicated

Admit to hospital if risk factors for life threatening asthma or based on patient’s social circumstances.

Severe asthma features

PEF 33% to 50% of best or predicted

SpO2 ≥ 92%

Cant complete sentences

Respiration ≥ 25 breaths/min

Pulse ≥ 110 beats/min Management

Nebulised SABA e.g. salbutamol 5mg (preferably oxygen driven)

Start prednisolone 40mg daily or start with hydrocortisone i.v. 100mg

Admit to hospital if the response to treatment is poor or if there are risk factors for life threatening asthma or based on patient’s social circumstances

Life-threatening asthma features

PEF <33% of best or predicted

SpO2 < 92%

Silent chest, cyanosis or poor respiratory effort

Arrhythmia or hypotension

Exhaustion, altered consciousness Management

Oxygen to maintain SpO2 94-98%

Nebulised SABA and antimuscarinic agent e.g. salbutamol 5mg plus ipratropium 0.5mg (preferably oxygen driven)

Start prednisolone 40mg daily or start with hydrocortisone i.v. 100mg

Admit to hospital


6


References:

1. BTS/SIGN British Guideline on the Management of Asthma, June 2019 https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ 2. Nice evidence summary for Tiotropium Respimat in Asthma https://www.nice.org.uk/advice/esnm55 3. www.medicines.org.uk – all drug files accessed 4. British National Formulary BMA 2019. https://www.medicinescomplete.com/#/browse/bnf 5. Why asthma still kills. National Review of Asthma Deaths Royal College of Physicians, August 2015

https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

Useful websites:

Inhaler technique videos: https://www.rightbreathe.com/ Personalised asthma action plan: https://www.asthma.org.uk/globalassets/health-advice/resources/adults/adult-asthma-action-plan.pdf Miscellaneous resources at Primary Care Respiratory Society: https://www.pcrs-uk.org/

North Staffordshire Joint Formulary: http://www.northstaffordshirejointformulary.nhs.uk/default.asp South Staffordshire Joint Formulary: http://www.southstaffordshirejointformulary.nhs.uk/ Profile of inhalers listed in local formularies: Link will be added once both the guidelines and inhaler list has been approved by the APG/APC

Further information If you have any queries about this guidelines please contact the authors: Dr Mukesh Singh GPWSPI Respiratory Medicine, Respiratory Clinical Lead for Stoke-on-Trent and Staffordshire CCGs Horsefair Practice, Rugeley Email: [email protected] Medicines optimisation team, Staffordshire Email: [email protected]

https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/

https://www.nice.org.uk/advice/esnm55

http://www.medicines.org.uk/

https://www.medicinescomplete.com/#/browse/bnf

https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

https://www.rightbreathe.com/


https://www.pcrs-uk.org/

http://www.northstaffordshirejointformulary.nhs.uk/default.asp


mailto:[email protected]

7


Document ratification

Committee/Group Date approved

North Staffordshire Area Prescribing Committee 28 August 2019

South Staffordshire Area Prescribing Group 20 September 2019

Cannock Chase Membership Board 8 October 2019

East Staffordshire Steering Group 15 October 2019

Seisdon Peninsula Locality Board 13 November 2019

Stafford and Surrounds Membership Board 1 October 2019

Tamworth, Lichfield and Burntwood Joint Locality Board 8 October 2019

8


Appendix 1 – Inhaler Profile Prescribe all inhalers by Brand Name

9


10


Note: Prices taken from BNF Online, accessed September 2019 - DPI = Dry-powder Inhaler - MDI = Metered Dose Inhaler Spacers - wash weekly, do NOT wipe dry. Replace every 6 to 12 months.

6mcg/100mcg Fostair √ √ MDI Aerochamber Plus 1-2 puffs Twice daily

29.32 At 1 puff daily

will last Two

months (120 doses)

LABA/ICS

combination (Long

acting Beta2 Agonist

& Inhaled

Corticosteroid)

6mcg/200mcg Fostair √ √ MDI Aerochamber Plus 1-2 puffs Twice daily


will last Two

months (120 doses)

6mcg/100mcgFostair

NEXThalerNot listed √ DPI − 1-2 puffs Twice daily


will last Two

months (120 doses)

6mcg/200mcgFostair

NEXThalerNot listed √ DPI − 1-2 puffs Twice daily


will last Two

months (120 doses)

6mcg/200mcg √ √ − 1 puff Twice daily


will last Two

months (120 doses)

12mcg/400mcg √ √ − 1 puff Twice daily 28.00 (60 doses)

4.5mcg/160mcg √ √


will last Two

months (120 doses)

9mcg/320mcg √ √ 28.00 (60 doses)

22mcg/92mcg √ √ 22.00 (30 doses)

22mcg/184mcg √ √ 29.50 (30 doses)

25mcg/ 125mcg 23.45 (120 doses)

25mcg/250mcg 29.32 (120 doses)

5mcg/125mcg 28.00 (120 doses)

10mcg/250mcg 45.56 (120 doses)

Formoterol/

Beclometasone

Formoterol/

Beclometasone

Symbicort

Turbohaler

DPI

DPI

DPI

−

−

1 puff Twice Daily

1 puff Once daily

Formoterol/

Budesonide

Vilanterol/ Fluticasone

DuoResp

Spiromax

Relvar Ellipta

Seretide

Evohaler1-2 puffs Twice daily

MDI 1-2 puffs Twice dailyFlutiformFormoterol/ Fluticasone √ √ Aerochamber Plus

Salmeterol/ Fluticasone Volumatic SpacerMDINot listed√

asthma prescribing guidelines – adults and children over ...€¦ · pharmacotherapy based on...

Documents